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Work environment

Healthcare organizations need to identify risks and hazards in their processes and systems (1). A hazard is something that can cause harm. A risk is the chance, high or low, that any hazard will actually cause somebody harm.

Examples of workplace hazards include drug labels, on-screen displays and the usability of devices such as infusion pumps. Complexity increases the likelihood of error. Nurses will often try to bridge "gaps" and try to make complex systems work. Organisations may introduce policies and guidelines and worsen the situation.  New technologies may address some safety issues but can also introduce novel forms of error (2).

An understanding of human factors can help with design considerations of work processes, facilities or devices. Standardisation and simplicity can be key organising principles and help people focus on systems not just individual elements (3).

Tools and interventions

Perhaps the best known method for investigating safety incidents is Root Cause Analysis (RCA). The technique is widely promoted in health care. But this technique is retrospective and analyses single events.

Root cause analysis (RCA) is designed to explore the contributing factors to adverse clinical events. The process is based on a sequence of questions: What happened? How did it happen? Why did it happen? What can be done to prevent it from happening again?
Prospective hazard analysis (PHA) techniques are still new to healthcare (4). Other methods include 5 whys analysis, fishbone diagrams, problem tree analysis and the Seven-S Model. These methods can be used separately or in combination to make sense of the risks and hazards that are a threat to patient safety.


1. Legge A (2009) A review of the top ten health technology hazards and how to minimise the risks. Nursing Times 105(32-33) Aug 18-31, pp.17-19.

2. RCN (2009) eHealth: making IT SAFER, London: RCN. 

3. NPSA (2010) Lessons from high hazard industries for healthcare. NPSA.

4. Card AJ et al. (2012) Successful risk assessment may not always lead to successful risk control: A systematic literature review of risk control after root cause analysis, Journal of Healthcare Risk Management, 31(3), pp.6-12.